Edinburgh Headway Group Referral/Application for Services

To reduce delays in processing your application, please complete all sections where possible. Please PRINT all information clearly.

Service applying for: Day Service* Brain Injury Carers Project

*please note there is a daily charge for Day Service, please contact the office for further information

Personal Information

Name of person with Acquired Brain Injury:
Sex: M F / Date of Birth: / / /
Address:
Mobile Phone : / Home Telephone:
Email address:
Nationality: / English Spoken? / Y N / Language: (if N)
Name of GP: / GP Telephone:
Address of GP:

Nominated Family Member/Carer

Please give the name of a family member or carer who may be contacted by Headway

Is this person the emergency contact person also?  Yes  No

Name: / Relationship to client:
Address: / Telephone:
Email:
Would this person be interested in receiving information about the Brain Injury Carers Project?
(see attached)
 Yes  No

Emergency Contact

If the nominated family member is not the emergency contact person, please identify on the lines below the name and telephone number of an emergency contact for the person applying for services:

Name of an emergency contact person for applicant:______

Applicant’s relationship to that person (e.g. partner, wife, husband, friend etc.) ______

Emergency contact mobile / landline number: ______

Source of Referral

Name of person completing this form/referral agent:
Please provide name of agency if professional:
Contact Telephone: / Relationship to client:
Contact email:
Contact address:
How did you hear about Edinburgh Headway Group?

Additional information is required from professionals involved in the persons care. Please nominate someone who would be able to provide us with information to inform our risk assessment.

Name of person to contact for a risk assessment:
Relationship to client: / Contact Telephone:
Contact address:

Details of Acquired Brain Injury (ABI)

Cause of Injury:
Please specify, e.g. Road Traffic Accident, Fall, Stroke, Haemorrhage, Assault etc.
Date of Injury:
Please provide the names, addresses and telephone numbers of the following if applicable
(please continue on a separate sheet if you need):
Name of Hospitals/Centres Attended since Injury
e.g. RIE, WGH, Charles Bell, Robert Ferguson, Physiotherapy, Occupational therapy etc. / Date from/to / Name of Consultant/ Professional

Current Needs and Difficulties

Does the client have any difficulty in the following areas as a result of the braininjury?
Physical: Please specify which of the following applies (e.g. Vision, Hearing, Weakness, Reduced Mobility, Fatigue/Tiredness, Epilepsyetc.)
Cognitive: Please specify which of the following applies (e.g., Attention, Memory, Planning, Orientation, Communication, Speech,Lack of Motivation, Sleep Disturbance, Irregular Sleep Pattern, etc.)
Behaviour: Please specify which of the following applies (e.g., Irritability, Aggression, Inappropriate/Antisocial, Impulsivity, etc.)
Emotion: Please specify which of the following applies (e.g., Mood Swings, Depression, Anxiety, Reduced Confidence, Anger etc.)
Reduced Awareness/Insight: Please give details
Current Social Situation: Please specify your current living and employment situation:
Live Alone / Y N / Live in permanent Accommodation / Y N
Live with Parents / Y N / Live in temporary Accommodation / Y N
Live with Spouse/Partner / Y N / Other (please specify) / Y N
Currently Employed / Y N
Currently Engaged in Training / Y N
Other activities you are involved in:
Functional/Personal Needs: Please specify (e.g., eating, drinking, toileting, transfers unaided)
Please list all current medication:
Please list the services the client is currently attending or applied to:
Reason for referral/expectations:
PLEASE ENSURE YOU CLEARLY STATE THE REASON FOR APPLYING TO OUR SERVICE
PLEASE STATE ANY PARTICULAR AREAS OF INTEREST OR INTEREST IN SPECIFIC ACTIVITIES WHICH WILL HELP US TO PROCESS YOUR APPLICATION

Consent to be Signed by Applicant (please tick all)

Y N
I give consent for information on my medical history to be released to Edinburgh Headway Group
I give consent for Edinburgh Headway Group to maintain all personal data concerning my medical history relevant to providing me with rehabilitative services
I give consent for Edinburgh Headway Group to release reports and information on my rehabilitation and progress to my G.P or other professionals involved in my care, when required.
Applicant’sSignature: / Date:

Consent Signed by Representative on behalf of Applicant

If the person referred wishes to give consent but is unable to sign the consent form, it may be signed below on their behalf by a representative.
I have discussed the above information about the provision of consent with (name of referred individual) ______. I can confirm that he/she wishes to give consent Edinburgh Headway Groupto obtain his/her background information from relevant organisations/individuals. I can also confirm that he/she understands that he/she can revoke this consent at any time.
Signature of Representative: ______
Date: ______
Relationship to Person Referred: ______
(i.e. Next of Kin, Friend, Parent or legal guardian)

In line with the Data Protection Act 2003, any information (including electronic information) received by or disclosed about individuals will only be held by Edinburgh Headway Group with regards to the intended purpose i.e. to assess a referred person’s needs in order to identify if and how these organisations can meet their needs. If the person referred is offered a service, the assessment information will remain on the individual’s file.

Please return this completed form to:

Edinburgh Headway Group, Headway House, Astley Ainslie Hospital, Canaan Lane, Edinburgh EH9 2HL

Edinburgh Headway Group (SC006528) Approved Referral FormMarch 2016Page 1 of 5